Over the course of her career in public health, Dawn Emerick has dealt with hurricanes in Florida and wildfires in Oregon. Now, just over three weeks into her job as metro health director for San Antonio, Emerick is dealing nonstop with the coronavirus.

“From day one, I’ve been dealing with this emergency,” she says. “I haven’t met all of my staff yet.”

San Antonio is coping with six active cases of coronavirus, having received travelers returning from Wuhan, China, and passengers from the Diamond Princess cruise ship. Dozens more are being monitored under quarantine, although many are set to be released on Monday.

Emerick may be stressed, but she’s not worried. San Antonio is well-equipped, with large numbers of hospitals, robust fire and emergency management agencies and a strong military presence.

The U.S. public health system as a whole, after all, has largely held up to many of the most dire global outbreaks in recent years, including SARS, Zika, H1N1 and Ebola.

In San Antonio, the health department has longstanding emergency response plans it’s adapting and putting into action. “The disease, the specific coronavirus, is different, but your response to respiratory disease is the same,” Emerick says. “We’re not going to deviate from that.”

Around the country, state and local health departments are implementing their plans for dealing with disease outbreaks. Following guidance from the federal Centers for Disease Control and Prevention (CDC), they’re issuing health and hygiene instructions to the public, while stepping up their coordination with other agencies and other levels of government, as well as their immediate neighbors.

“The health department prepares for this sort of thing all year round,” Laura Curran, the county executive in Nassau County, N.Y., said at a news conference last week. “We have a Medical Reserve Corps of volunteers, medical professionals — a thousand of them — who are ready for any kind of situation that needs their attention.”

The Medical Reserve Corps program, which began in the wake of the 2001 terrorist attacks, now has 839 units around the country, with 175,000 volunteers on tap.

Still, while health departments know the drill, they also acknowledge they now face a challenge that, at this point, remains unknowable in terms of its ultimate scope.

“If this is a baseball game, we’re in batting practice now,” says Jeffrey Duchin, the top public health officer for Seattle and King County, Wash. “The game hasn’t started yet.”

Duchin spoke prior to the death of two men in King County over the weekend, the first known deaths from the coronavirus in the U.S. A review of two infection cases in the county suggests that the virus may have been present in the state for several weeks. On Saturday, Washington Gov. Jay Inslee issued an emergency proclamation, “directing state agencies to use all resources necessary to prepare for and respond to the outbreak,” according to a news release.

Failing the Prevention Test

Everyone knows the saying that an ounce of prevention is worth a pound of cure. That’s an approach rarely put into practice when it comes to public health.

Most medical dollars are devoted to individual treatment and care. Less than 3 percent of U.S. health-care spending is devoted to public health.

Those dollars aren’t all distributed evenly. The American health system is highly fragmented. Not every community has the resources of a San Antonio or Seattle. The amount of dollars and personnel devoted to public health varies widely from state to state and, of course, within states at the city and county levels. That makes a uniformly robust response to a new threat impossible.

“This will spread within the weakest links of our public health systems,” says Ali Khan, dean of the University of Nebraska College of Public Health. “This virus is going to exploit all of the inequities and variabilities within our health system.”

Federal spending on public health programs such as hospital preparedness has declined over the past decade. More than 55,000 jobs were cut at local health departments between 2008 and 2017, according to the Trust for America’s Health.

Despite all that, Khan notes that the CDC’s public health emergency preparedness level — a set of measures looking at system capabilities and planning — has increased since 2013, rising from 5.9 to 6.7 on a scale of 10.

“The national preparedness level has gone up,” says Khan, a former director of the CDC’s Office of Public Health Preparedness and Response. “But the point is, it’s still low.”

Strains on the System

State and local governments are still largely gearing up, holding internal coordination meetings and spreading the word to the public about prevention measures such as washing hands and surfaces. “One technology development that has had an adverse impact is the amount of disinformation out there,” says Bill Hazel, a former Virginia health secretary.

Some local health departments are already tracing contacts of people who may have been exposed to the virus. That alone can be a massive task. A student who had traveled to Wuhan showed up at a hospital in Lawrence, Kan., with signs of respiratory illness. The state health department traced his contacts and was ready to notify 403 people. “We had a phone bank. We were ready to go,” Kansas Health Secretary Lee Norman told The Kansas City Star.

It turned out to be a false alarm, but Norman noted that the state had to wait five days to get test results back from the CDC. The number of test kits are limited — the state of California only has about 200, Gov. Gavin Newsom said at a news conference on Thursday — and states are having to wait on the CDC for results.

Officials in Rhode Island are alerting about 40 people who had contact with a man who had traveled to Italy and is now the state’s first positive case. “We are not seeing widespread community transmission in Rhode Island, and that means the general level of risk for Rhode Islanders is still low,” Department of Health Director Nicole Alexander-Scott said Sunday.

There are other challenges. The lack of testing capacity is only one shortfall. Supply chains are bound to be disrupted — particularly with China being such a major manufacturer of prescription drugs.

With most of the initial patients in self-isolation at home, doctors and nurses are having to make house calls. That takes time. And, when patients have to be transported, emergency personnel will need protective gear.

“Depending on the numbers involved, the health-care system could be overwhelmed quickly,” Hazel says.

That’s why containment is so important. Many health experts believe it’s inevitable that the coronavirus will be transmitted locally in the U.S. But every day before that happens is a day closer to developing a vaccine, while also allowing hospitals more time to procure masks and ventilators.

“The piece that’s coming more into focus now is the need to prepare for a potential large outbreak,” says Duchin, the Seattle-King County health officer. “We definitely need to prepare for many more people needing health care.”

The Politicized Federal Response

State and local health officials insist that they’re up to the challenge. Emergency operations centers are being activated to allow for coordinated response. Pandemic flu plans are being reviewed, adapted and implemented.

“We are gearing up for a big outreach message which is to prepare, don’t panic,” says Emerick, the San Antonio health official. “We do see a lot of folks who are getting very nervous about what’s going on.”

States, cities and counties are putting their plans to work, but so far they’re doing so in the absence of federal financial support. “The federal government needs to step in and support this on-the-ground effort with money,” says Chrissie Juliano, executive director of the Big Cities Health Coalition, which represents health officers in the 30 largest cities. “The public health system is going to respond, but they’re going to need to backfill dollars that are spent.”

President Trump has called for a $2.5 billion package to respond to the coronavirus, while Charles Schumer, the Democratic leader in the Senate, wants $8.5 billion. Presumably, the final number will fall somewhere in between.

But it will take some time for that money to flow down to the local level. After Congress passed a $1.1 billion package to combat Zika in 2016, it took 233 days for that money to reach local governments, Juliano says.

So far, politicians in Washington haven’t been able to put aside their political differences to act with a sense of urgency.

Trump has accused Democrats and the media of overhyping the coronavirus for political purposes. Appearing at the Conservative Political Action Conference on Friday, acting White House Chief of Staff Mick Mulvaney said the media is exaggerating the threat because “they think this will bring down the president. That’s what this is all about.” He also noted, however, that schools might be closed and public transit disrupted by the virus.

Elizabeth Warren, a Democratic senator and presidential candidate, has introduced a bill that would shift all the funding from Trump’s border wall to the coronavirus fight. On Friday, a group of House Republicans walked out of a coronavirus briefing after Connecticut Democratic Rep. Rosa DeLauro made remarks lambasting the administration’s response. Inslee, the Democratic governor of Washington, took to Twitter to criticize the administration for not sticking to the science.

“The public health response depends on people trusting in the system and trusting in government,” Juliano says. “It’s very difficult for folks on the ground when there’s not a consistent message from the federal government, or there’s a local message that’s different from the federal messaging.”

Prior to Trump enlisting Pence to run the administration’s response and communications, the White House and federal health agencies had issued contradictory statements. All the bickering and partisanship hasn’t helped to foster a sense of credibility or public trust in government.

Khan says that the administration has finally taken steps that should have been taken weeks ago. “At long last, we have an established leadership structure for the nation,” he says. “We now have a czar and we have a brilliant scientist who is now the response leader," referring to Deborah Birx, an AIDS expert and global health ambassador who was just named as coronavirus response coordinator.

Some critics of the administration have complained about having Pence, rather than a doctor or scientist out front. Appearing on CNN Sunday, Pence said that the risk of infection to the average American remains low. “This weekend, more than 15,000 testing kits have been released,” Pence said. “Also, the FDA has approved a testing regimen that state and local officials can be using.”

Khan says that the main thing is to have someone clearly in charge. “Having the vice president as czar, whatever you think of his scientific acumen — his job isn’t a scientific job,” says Khan, the author of a 2016 book, The Next Pandemic. “It’s a political job, making sure the interagency response works.”

But he warned that the threat posed by the coronavirus should not be taken lightly.

“I’m not somebody who dismisses this as just another respiratory infection,” Khan says. “This is not a disease to discount — especially if you love your grandparents. This disease looks quite mild for young people, but as you start getting 50 or older, and especially if you have some additional illnesses, this becomes quite deadly.”